Thinking beyond a spectrum of alcohol use

It’s January, so I shouldn’t really be surprised there seem to be a lot of stories about alcohol in the press and online.  The particular one that’s caught my eye is this academic response to the ‘new sobriety’ movement, and an exchange on Twitter.

Alcohol Change UK could claim all this as a success, given that much of this is due to the prominence of ‘Dry January’.  (For those who aren’t aware, this is a voluntary commitment to give up alcohol for the month of January.)

Last year (as in most years) I wrote about some of my misgivings about the campaign - or rather, about how it’s interpreted.

Perhaps most obviously, we know that the people most in need of ‘behaviour change’ (and therefore support) tend not to undertake Dry January, and if they do then they’re less likely to complete it successfully.

One interpretation would be that this isn’t necessarily a bad thing: stopping completely in the way Dry January implies isn’t appropriate for some of the people most in need of support, if they’re physically dependent on alcohol.  And we shouldn’t be surprised that the people who have the most entrenched issues find it hardest to give up – that’s the definition of having a more serious problem.

What’s been on my mind this year is a slightly broader interpretation of this issue.  It’s not entirely new, but I think it’s worth highlighting. And as I do, I think it’s also worth mentioning that, unlike last year, I’m actually doing Dry January this year.*  This is absolutely not a post attacking the campaign.  The point is that I think anyone in the field should feel obliged to use this moment of media interest to raise wider questions around alcohol, rather than simply trumpeting the merits of ‘choosing’ to stop drinking for a month.

If you look at the evaluation of Dry January, it tells us what we’d expect for any similar behaviour-change programme: successful participants (defined as completing the month without consuming any alcohol) are most likely to be women, to have a university degree, and to be on a higher-than-average income.  They’re also more likely to report good physical health at the start of the month.

As I say, this isn’t really a surprise.  We know from other areas of public health that these characteristics make people more likely to find success in these kind of campaigns based around individual choice.  And that’s fine; it’s horses for courses – some approaches will work for some people and not others.

The danger is that those factors that make people more likely to find behaviour change approaches helpful are exactly those that mean they’re less at risk of harm in the first place.  Because harm from alcohol isn’t simply correlated with consumption.  (The ‘alcohol harm paradox’ shows that although it’s the richest in society who tend to drink the most, it’s the poorest who suffer the most health harm related to alcohol.)

This is where it gets interesting.  At the same time as there have been various pieces written about Dry January, I’ve seen a few things about ‘alcoholism’ and the idea of a spectrum.  In fact, they’re kind of prompted by each other.

Amy Dresner has expressed some frustration with the ‘new sobriety’ movement (which some would see Dry January as being linked with), because it underplays how difficult just ‘choosing’ not to drink can be for those with a more serious issue – which she labels as ‘alcoholism’.  I’ve written about this idea of alcoholism before,

James Morris has suggested that this perpetuates an unhelpful alcoholic/not alcoholic binary, when the reality is that people will be facing a range of issues across a whole spectrum.  Just because you don’t fit the classic definition of ‘alcoholic’, doesn’t mean you don’t have an issue with alcohol.

I guess inevitable to some degree Dry Jan etc will be contrasted with abstinence based recovery etc.

Again though this is a false binary - the 'alcoholic or not' qu. may be a default reference point but for most alternative framings need wider promotion

— James Morris (@jamesmorris24) 2 January 2020

What I want to suggest here is that we need to see this spectrum as something more than a one-dimensional discussion of the severity of alcohol issues.  This has been proposed before, with people like David Nutt saying the best way to understand problematic substance use would be to abandon terms like ‘addiction’ or ‘alcoholism’ and simply look at ‘heavy use over time’.

Currently, though, when people think about problems with alcohol, these aren’t just about alcohol.  In diagnosing a ‘substance use disorder’ you might well look at consequences to someone’s home, relationship, work and so on.  In very few cases are these issues likely to be solely the result of substance use.  Things can enter a vicious circle, of course (substance use might intensify as other problems mount, as a form of escapism that only serves to make things worse).  But I mean something more than that: other issues may mean that the consequences of a particular level of alcohol use are worse for one person compared to another.

In a strange way, the reason there’s potentially tension between people who subscribe to a narrow definition of ‘alcoholism’ and those who advocate ‘new sobriety’ is that they share a lot of the same ground.  Alcohol is seen as absolutely crucial to both.

According to AA, the ‘alcoholic’ is a specific category of person who effectively has an ‘allergy’ to alcohol, and is best living without it entirely.  According to some of ‘new sobriety’ narratives, all the person had to do was remove alcohol from their life and they were suddenly able to wake up early with enthusiasm for their job (or with the passion and clarity of vision to start something completely new), and able to buy a house, and build better relationships with friends, family and lovers.

First, I should point out that both of these are caricatures.  In AA it’s widely accepted that the hard work starts once you’ve stopped drinking, and there are plenty of ‘new sobriety’ style advocates who would say the same.  And the reason the narratives are similar is because often we’re talking about people who have faced the same, serious issues.  As Amy Dresner points out, ‘If you CANNOT do a full month without drinking or if your life gets exponentially better when you stop drinking you might actually be an alcoholic’.  Chelsey Flood and Lucy Rocca are particularly good examples of people who could be seen to bridge the gap between these two camps.

But the point remains: in both narratives, alcohol is central and fundamental.  For ‘alcoholics’ there’s no life without removing alcohol, and for ‘new sobriety’ advocates’, just removing alcohol improves life immeasurably.

And this helps explain why Dry January works for some people.  Let’s go back to those successful Dry January participants.  They didn’t just tend to be healthy, highly educated, female and well-off.  They tended to believe they had a problem with alcohol, and this was confirmed through their AUDIT questionnaire (though of course this is dependent on self-reporting – we may each define problems and issues in different ways).

This makes sense psychologically and sociologically: we’re more likely to address a problem and persevere with solutions if (a) we genuinely believe it’s serious; and (b) we have some key resources behind us (‘recovery capital’ as they’re sometimes called) to support us.

In reality, for most of us who have issues in our lives and who drink what some people would see as ‘too much’, the precise role of alcohol is less clear.  Perhaps I’ll be proved wrong by the end of the month, but my previous experience suggests that I do not some hidden passion or clarity of vision that is simply waiting to be unleashed once alcohol is removed from my life.  And I can’t see that the things that make me angry or upset, for example, are going to be resolved by drinking less.

But it’s about more than that: it’s that for plenty of people you could remove the alcohol from their lives and things wouldn’t get demonstrably better.  Or it’s not just about removing alcohol to reduce their risk of health damage.  (Think of that alcohol harm paradox work.)

Therefore, if there’s an axis of ‘severity of alcohol use disorder’ that’s relevant to problems, there could also be another axis representing how much this is really about alcohol.

What does this mean for policy and advocacy though?

It means that anyone who’s serious about reducing ‘alcohol-related harm’ needs to think about more than just how many units people consume.  This is partly about patterns of consumption, but it’s also about wider social factors – exactly those things that make some Dry January participants more likely to succeed than others: wider health, employment, education, income, and so on.

This has clear implications for how we support people who do have issues with alcohol.  These can’t simply be addressed by appealing to individual choice, or by focusing on a person’s drinking.  There’s a need for services arranged around people’s actual lives as they live them.  (I’ve written about this before – for example here and here.)

There’s also a need for policies that address the wider structures that shape people’s choices and their lives – something that I’ve suggested in the past the sector has neglected, in its tendency to focus on a single initiative, whether that’s minimum unit pricing, alcohol labelling or Dry January.

So what does this mean for the value of Dry January?  It’s potentially helpful for a lot of people at an individual level, but for me its key contribution is about culture change, which then provides a space for policy change.

First, it prompts everyone to think about their alcohol consumption, and that fits perfectly with Alcohol Change UK’s admirable goal of getting everyone to make well-informed decisions.

Second, it provides an opportunity for commentators and policymakers to note that alcohol isn’t just any other commodity, and for all its strengths the individual-focused approach of Dry January doesn’t work for everyone, so we need more.

Anyone not making this case when talking about Dry January is, in my view, missing an opportunity, and even perpetuating health inequalities.

*Disclaimer: I did drink on 1^st January, so I’ve started late.  Someone who had come to our New Year’s Eve party had brought a ‘polypin’ of about 9 pints of locally-brewed beer, and not all of it got drunk.  My Presbyterian heritage of ‘waste-not-want-not’ in this instance overrode the Presbyterian tradition of temperance, and I drank the remainder on New Year’s Day in front of the football on the TV.